British Petroleum’s Wellness Program is Spewing Invalidity

A critical observation in Cracking Health Costs is you need not “challenge the data” to invalidate claims that wellness saves money. Instead, you can simply read the data as presented. You’ll find it usually invalidates itself.

Nowhere is that more true than in a study published this month by Mercer, Staywell and British Petroleum (“BP America”) in the Journal of Occupational and Environmental Medicine (JOEM). As we’ll demonstrate, the results completely contradict Staywell’s own statements, and are also mathematically impossible. Indeed, Mercer was a wise partner choice by BP America because their validations are often unconstrained by the limits of possibility. For instance, they validated massive savings both for infants in a North Carolina Medicaid program that did not enroll infants, and for a Georgia Medicaid disease management program that did not manage diseases, at least according to the FBI.

Along those lines, let’s see what happens when one compares the JOEM conclusion — that the Staywell wellness program for BP America achieved almost $20,000,000 in savings on 20,343 BP participants after only two short years – to the limits of possibility.

It turns out this overall savings claim of $1,000/person would require completely wiping out wellness-sensitive medical events (heart attacks, diabetes events etc.) not just on those 20,000+ people, but also on perhaps 40,000 of their closest friends. The authors elected not to disclose the change in wellness-sensitive medical events across the entire eligible population, perhaps because they were embarrassed by the size of the decline, if indeed those events declined at all.

The authors went a step farther and decided not to even acknowledge that a wellness program should reduce wellness-sensitive medical events, a perfectly logical nexus not unlike saying that an antihyperlipidemic drug should reduce cholesterol levels or an asthma rescue drug should improve breathing, or sunblock should prevent sunburn.

It’s not just the two of us who think logic should prevail in connecting wellness initiatives to wellness events. Health Affairs laid them out too, in a seminal 2013 study that Mercer and Staywell didn’t footnote despite being the most recent scholarly article on exactly this same topic. They also selectively omitted other key citations. The equally seminal RAND study – which concludes that wellness programs produce no two-year population-wide savings – also went unacknowledged.

Curiously biometric screens were noted as one of the sources of BP’s alleged savings, but this once again turns out to breach the wall of possibility: another – also unacknowledged — Health Affairs article showed that it is mathematically impossible not to lose money on biometric screens, which is why government agencies,expert panels and books warn against using them. (They can and do also harm patients, which is perhaps why most people only participate when threatened with large penalties, as was the case with BP, where 30% of their employees elected to forfeit $1200, to stay out of their program.)

These selective citation omissions are indicative of the wellness industry researchers’ distaste for facts. This is not to say that wellness researchers are stupid. Quite the opposite: they are smart enough to realize that facts are their worst nightmare.

The Data that Didn’t Bark in the Nighttime

And in this case, the most troubling fact is right in their own study, albeit buried deep enough (page eight) that the JOEM peer reviewers may not have noticed it. That is the percentage of people whose risk factors actually improved: 5.6%. As modest as this figure is, it actually excludes the people most likely to get worse– those who dropped out of the program and those who wanted nothing to do with it in the first place.

Understandably, the study authors decided not to draw attention to the simple division of the savings ($19,700,000) into the number of people who even theoretically could have avoided wellness-sensitive medical events (5.6% of 20,343, or 1,139 people), because that division would have yielded a whopping $17,300 in savings per person whose risks declined.

And once, again, the limits of possibility don’t stand a chance against Mercer and Staywell, for three reasons. $17,300 is:

Almost three times what a company spends in total on the average covered person`.

At least 30 times what a company spends on wellness-sensitive medical events for the average covered person.

This assumes there were any savings at all, which we’ll never know because recall they failed to disclose the wellness-sensitive medical event tally.

Lessons for Wellness Researchers

So, what can be learned from this valuable addition to our growing library of teaching tools for population health management, other than how easy it is for vendors and consultants to convince their HR clients in large corporations that they are saving massive sums of money through wellness?

First, the most sophisticated-sounding study designs in the world – and this one looks at least six figures worth of sophistication – can’t ignore the question: “Is this result even mathematically possible?”

Second, those expensive “matched control” study designs are worthless anyway when comparing actively motivated participants to unmotivated non-participants. You can match demographics but you can’t match the difference in mindset between (for example) smokers who want to quit and smokers who don’t. Health Fitness Corporation showed that would-be participants significantly outperform non-participants even without a program.

Third, researchers need to stop attributing all good things to wellness and instead employ a basic biostatistical tenet, which is that the outcome should bear some relationship to the intervention. In the case of wellness, that means a program designed to reduce wellness-sensitive risks should have its greatest if not only effect in avoidance of medical events of a wellness-sensitive nature.

Fourth, they need to understand the relationship between risk factor reduction and cost savings. As Why Nobody Believes the Numbers shows mathematically, costs decline about a tenth as much as risk factors decline, meaning that BP could attribute roughly a 0.56% decline in costs to the 5.6% risk factor decline. This 0.56% gross decline would be offset by more preventive physician visits, more preventive drugs, the cost of the program and incentives. It also assumes that the 5.6% itself figure is real, which it almost certainly isn’t because…

…Fifth, this industry needs to stop ignoring the overwhelming preponderance of facts that don’t support its belief system. In particular, it needs to stop citing the single company (Johnson & Johnson) which has a strong wellness culture that few others have duplicated , and instead look at RAND and (for example) IBM, Dow Chemical or Salt Lake County to see a much more realistic view of what companies can accomplish. Wellness industry leaders specialize in distorting fundamental scientific and analytic principles to meet their own needs. Increasingly, however, health policy experts are calling them on this, which means that there is hope for introducing integrity into the wellness outcomes reporting process.

Along with their distaste for facts is a distaste for arithmetic. Page eight of the JOEM paper asserts that “there are no industry standards on how to calculate ROI…” They could easily have added: “…because most vendors, including us, refuse to disclose the rate of wellness-sensitive medical events, which would be the obvious choice as an industry standard if we were able to actually reduce these events.” Instead the vendor association uses an invalid consensus methodology, making wellness/disease management the only industry where mathematical proof is trumped by popular vote.

Finally, industry supporters need to stop citing the single article in a first-tier journal with a positive finding about wellness’s impact on health spending. That article is now approaching its fourth birthday, it was a meta-analysis of studies mostly drawn from third-tier journals that among them had never published an article that found anything other than positive results from wellness (there is even a term for this — “publication bias”), and even its authors no longer seriously defend it. (Reflecting the dearth of more recent positive press in first-tier journals, a leading wellness proponent recently wrote that this article “should be cited much more frequently by health promotion and wellness professionals.)

This industry needs to acknowledge that almost all credible recent literature – ours or anyone else’s –finds largely failure, and then develop or identify some best practices. Hence we once again invite people to identify a single wellness vendor that saves money by reducing population-wide wellness-sensitive medical events, for us to highlight in a future column.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness. An iconoclast to the core, he is the author of the Khanna On Health Blog. He is also the Wellness Editor-At-Large for THCB.

Then Ron Goetzel’s (who runs the committee that gives out the award) says we are bullying him for asking him questions like, why he always gives awards to his sponsors no matter how obviously corrupt and dishonest their programs are. http://theysaidwhat.net/2015/02/28/goetzel-apology-2/

- Share

Guest

Mary

Jan 12, 2015

The Wellness Industry, where big bugs are involved, has left the Healthcare arena into layman’s arena. Everyone who can use their ‘Google finger’ to look up any subject believe they are now experts. Unfortunately they do not understand the complexities of interpreting the data.
Physicians who deliver healthcare and manage risk factors in their patients and Medical epidemiologists should be vetting these so called Wellness vendors. Unfortunately the appropriate credentialed professionals are no longer in charge

- Share

Guest

Lee Long

Jul 16, 2014

What they don’t tell you is if you don’t participate they double or triple your health insurance premiums.

reverse phone lookup usa whoah this blog is wonderful i love reading your articles.
Keep up the great paintings! You recognize, many persons are looking around
for this info, you could help them greatly. reverse
phone lookup free results

- Share

Guest

Mary

Oct 23, 2013

The research shows that the biggest impact of health behavior comes from the patient’s encounter with their physician. A one on one encounter. Individuals are more likely to take the advise of a physician and follow through on health behavior than based on some Wellness Program.

I realize I don’t have much of a chance of convincing you, since as Upton Sinclair noted, it’s impossible to prove something to someone whose salary depends on believing hte opposite, but here goes:

(1) like it or not, only 1103 people’s risk factors declined. Sorry. Dropouts and non-participants were much more likely to have risk factor increases, os probably on balance there was close to no change.

(3) Since you don’t understand the concept of wellness-sensitive medical events, you should probably learn what they are before getting in over your head here.

(4) It probably is the case that healthier people do better in surgeries but wellness programs that only make 1103 people a little healthier aren’t going to make a bit of difference.

(5) You contradicted yourself. BP says it saved $20MM by basically managing current cases (in a 2-year period) so whatever elusive long-term goal you are referring to, even if it could be achieved, wouldn’t hvae counted towards that $20-MM.

By the way, the wheels have completely fallen off your wellness bus. Even Kate Baicker — whose article provides the only ROI support for wellness in a real journal (not the JOEM etc., which are house organs) — just recanted. You are now left with no articles in any real journal on your side, with more bad news coming out in a real journal within a few months.

And your ethically challenged C Everett Koop Award Committee won’t retract the award it gave to Nebraska even though Nebraska has admitted fabricating the data. What would Dr Koop think of that?

So once you have an industry that has any semblance of intellectual backing and ethics, you can raise more points. But you people better get your own house in order first.

Al, as requested, here are bullets from our LinkedIn discussion regarding the flaws in your analysis to allow for a point counterpoint discussion.
1. Your analysis hinges on the 5.6%, which you refer to as percentage of people whose risk factors actually improved, but the 5.6% is actually the reduction in the average number of lifestyle-related health risks among all repeat HQ participants. So you are taking an average reduction across the entire population and using it as if it were a percentage of the population that were impacted to come up with your unbelievable cost reduction figure. Since your whole article hinges on this one factor, the rest of your conclusions seem to fall apart.
2. You rely an awful lot upon a $400 figure for a theoretical maximum, which seems too low. From the Medical Expenditure Panel Surveys average of 2006 through 2008 the costs associated with risk factor-related conditions account for 36% of total medical expenditures, or approximately $1,285 per working age adult (presumably the costs and potential impact has increased since then). Recognizing that not all of the costs are associated with lifestyle factors, epidemiological studies through the Global Burden of Disease study developed attribution factors, which when applied to these conditions, reduces this figure to approximately $649 per working age adult. Some fraction of this can be influenced by wellness if you were able to get everyone to their optimal health, but this is still more than your theoretical maximum of $400.

In addition to looking at the current costs of those with some risk factor related health condition, there are aspects of wellness that don’t get accounted for in looking at current cost levels related to risk factor-related conditions:

1) Impact wellness has on care outcomes – We know that if someone is physically, emotionally and spiritually healthier, their procedure success rate, recovery time, ALOS and chance of no complication/readmission is better, pretty much for any type of procedure.
2) Reduction of future incidence – If someone is currently healthy, but not exhibiting healthy lifestyle factors, there is a higher incidence that they will contract a chronic condition in the future.
3) Management of Incidence – If the current unhealthy behaviors continue, the current costs will increase in the future. If people can change their behaviors, presumably it would influence by the behaviors of those with the conditions. This is a hard one to prove, so I say presumably, but ultimately the goal of wellness is to reduce or eliminate the development of future cases, not manage current ones.

3. You point to the Rand study as some gospel, but the four programs they evaluated are clearly ineffective programs based on the fact that they averaged only 40% participation. I wouldn’t point to that as a good analysis of effective programs. There are effective and ineffective programs and we as a profession need to be clear about the distinctions and what makes the difference.

Good question–thanks for the opportunity to clarify and you have an interesting point, though not one that changes the answer much.

The article says 5.6% is the reduction in the “average number of lifestyle-related risks” among “repeat participants.” That means if there were 20000 repeat participants, about 1100 might have temporarily (for that year between readings) lost some weight or quit smoking.

There are a huge humber of things wrong with the science here. To being with, most of those 1100, statistically speaking, will regain the weight and/or start smoking again. And also the concept of limiting your count of the risk factors to people who were motivated enough to participate twice is ludicrous: it leaves out the dropouts and non-participants who are much more likely to see a risk increase.

My result is simply taking the total savings and dividing it by those 1100 people whose risk declined.

However, if you assume THREE risk factors per person (and forgetting still about not counting the dropouts), then the total number of risk factors that went down would be 5.6% of 20,000 * 3, or roughly 3360 risk factors.

Now, divide that $20MM in savings by 3360 risk factors and you get about $6000/risk factor. This is a bit more than total spending per person, so it’s still impossible, and it’s still 60 times what Staywell says is possible. (Staywell is also overestimating what is possible on its own website, which we’ll address in another posting soon.)

- Share

Guest

Michael

Jul 22, 2013

I read the BP article before being pointed to this post and I’m trying to follow your argument. I don’t quite understand how you arrived at your $17,000/member savings. You multiply the number of participants (20,343) by 5.6%, which you say is the number of people who experienced a reduction in risk. The article says, however, that 5.6% is the reduction in “health risks” among the population. I took that to mean, for example, that the baseline average for a health risk score was 100 and the the sample year average was 94.4, a 5.6% reduction in risk and not 5.6% of the population reduced risk. Can you clarify?

thank you for your boldly anonymous comment. One of the interesting things about the wellness ignorati is that they don’t understand the way math works. Math is not a “debate” with points and counterpoints. Staywell claimed 100x the savings for BP it claims on its own website. It’s their own math — both statements can’t be true. Perhaps they should “debate” themselves.

Why, were you interested in ad-hominem as a mathematical proof? My comment is on your rhetorical style, and it’s just a suggestion. Math equations never result in statements like “Along with their distaste for facts is a distaste for arithmetic.”

- Share

Guest

John

Jul 19, 2013

Even if these articles have valid points for debate, you might consider that these companies don’t want to engage Al Lewis because he has a propensity for accusations that make him look like an internet troll. Nobody wants to be drawn in to a flame-war manufactured to help somebody sell books at their own expense.

- ShareHide Replies ∧

Guest

EtAli.Jr

Jan 12, 2015

Writing style aside, Mr. Lewis et. al. provide a very valuable service. The huge number of companies that have implemented such programs over the years and the costs of such programs begs the question (repeatedly) “where’s the beef”? I’ll settle for tofu or some veganoid substitute.

It’s just not there. Yet far too many have jumped on the wellness band wagon as it has far surprassed cotttage industry status and now looms large on the corporate landscape. Perhaps the C-suite does it for “corporate social responsibility” reasons? Perhaps it’s a distraction to placate associates with something that looks like it is an act done for them while the real work of hacking at insurance plan design goes on behind closed doors (anyone notice any excessive cost shifting of late?).

The numbers generated by biometry are an awkard part of this never ending drama. Again, what are they for? When a vendor draws one’s blood and peforms 30+ tests one has to realize something is way out of line. Such testing behavior raises many questions including what the devil are you going to do with all that useless if not harmful data (false positives)?

Yes, Al and company are somewhat taken with themselves; academic pedigrees seem quite important to them don’t they? Yet that posh academic experience they claim coupled with undoubtedly superior genetic substrate(s) has indeed produced the well oiled machine you witness when you read their blogs as well as the not so subtle microscopy they perform on errant thoughts and missives.

Style points are everything (an old girl friend once told me). I say there is a lot of room for different styles. Don’t you?

- Share

Guest

Al Lewis

Jan 13, 2015

Thanks for your comment and keep ’em coming.

Your theory may very well be accurate (I hadn’t really thought of it before) about why no one defends themselves. Others might not want to “get into the gutter.”

However, that doesn’t explain why, 24 named-vendor smackdowns later, none of the perps has even sent us a cease-and-desist letter, let alone sued us. We’re doing the best we can to encourage it, but so far no takers. We could use the PR and we would destroy them. We only publish a fraction of what we know because we can use only publicly available stuff. For many vendors we have ex-employee sources that usually say things like: “It’s even worse than you think.”

I agree with a lot of the other comments. This was a great post.
Wellness Program –A way of living that encourages good physical and mental health. It is a balanced lifestyle that includes an emphasis on the body, mind and spirit.

Analytics are becoming imperative to researchers in recruiting patients into studies, making
breakthrough discoveries, as well as monitoring the clinical implementation of these discoveries.
This webinar will be for organizations that want to leverage their enterprise data to power more
effective research.
Learn More...

We frequently accept crossposts from smaller blogs and major U.S. and International publications. You'll need syndication rights. Email a link to your submission.

WHAT WE'RE LOOKING FOR

Op-eds. Crossposts. Columns. Great ideas for improving the health care system. Pitches for healthcare-focused startups and business.Write ups of original research. Reviews of new healthcare products and startups. Data-driven analysis of health care trends. Policy proposals. E-mail us a copy of your piece in the body of your email or as a Google Doc. No phone calls please!

THCB PRESS

Healthcare focused e-books and videos for distribution via THCB and other channels like Amazon and Smashwords. Want to get involved? Send us a note telling us what you have in mind.
Proposals should be no more than one page in length.

HEALTH SYSTEM $#@!!!
If you've healthcare professional or consumer and have had a recent experience with the U.S. health care system, either for good or bad, that you want the world to know about, tell us about it. Have a good health care story you think we should know about? Send story ideas and tips to editor@thehealthcareblog.com.